Reducing errors through discharge medication reconciliation by pharmacy services

Objective. Adverse drug events are an important cause of admissions to hospitals. Discrepancies in admission and discharge medications can contribute significantly to these adverse events. Patients are at risk of discrepancies in medications any time they experience a transition of care. Medication discrepancies occur more commonly when patients are discharged. Prevention of errors by undergoing medication reconciliation with review by a pharmacist can help avoid medication discrepancy-related errors. The objective of this study was to determine whether integration of pharmacist review in the process of medication reconciliation at discharge identifies and corrects discrepancies. Methods. In the study population of internal medicine patients cared for by hospitalist physicians, we prospectively collected data from medication lists via chart review and patient interview and identified, using a pharmacist, any medication discrepancies. We then counted the number of discrepancies for each patient and categorized them by severity of potential adverse effect to the patient. Results. There were 63 medication discrepancies in 104 included patients found by pharmacist's review and 41% (43) of patients had at least one medication discrepancy. Patients with 8 or more discharge medications were found to be at an increased risk of discrepancy (OR 8.5, p<0.001, 95% CI 2.8,25.5). Most discrepancies were considered minimal risk, 44.4% (28/63), or moderate risk, 49.2% (20/63) for adverse effect. Conclusion. About 2 out of 5 patients on the hospitalist service studied have discrepancies in their medications at discharge that can be identified and corrected by pharmacist intervention. Inclusion of pharmacists could improve the process by correcting these discrepancies to help avoid preventable adverse drug events.